Over the last couple of months, I have been discussing the use of external fixation in pediatric surgery (see http://tinyurl.com/24c3npl  ). I have discussed the applications and the basics of the technique. For this month’s blog, I would like to share some pearls and tips from my experience with this technique over the years.
As I have mentioned previously, patient and family education is key. This is much more of a team effort than most other surgical interventions we perform. Proper education and understanding on part of the patient and family are paramount to the success of the procedure and technique.
I go so far as to give the patient a diagram of how to manipulate the device for callus distraction. Depending on the mini-rail system I choose, I may even put markings on the distraction portion of the device to give patients a clear indication of what they need to manipulate and how. Some devices are easier to mark than others but, in the end, any mini-rail system has this inherently built into the device.
It is just a matter of getting the family to understand what we need to manipulate and what we need to leave alone. In one instance, I had a patient who “forgot” to start the distraction after the initial compression phase and the osteotomy healed prematurely. This is definitely where this process has its negatives.
It is also important to understand that the representatives of the manufacturer of the particular mini-rail system need to give you all the peripheral tools required to adjust and tighten the device. Especially when following the callus distraction protocol, it is necessary to check for tightness of the remaining portions of the device and tighten accordingly. I like to ask the company rep for two sets of these tools, one for me and one for the patient. This way, I have a set if patients leave theirs at home.
I also tend to see my distraction patients quite frequently for radiographs. The calcaneus is quite a hypervascular bone and it always amazes me how quickly it can ossify after an osteotomy in the pediatric population. I generally see these patients at least once a week to check that everything is going according to plan. This also gives me an idea of how much more distraction is required.
Patients tend to start having pain at the end limit of the distraction process. They will usually verbalize this to you during one of their follow-up visits. I usually take this as a cue to ask them to stop distracting, even if they have not achieved the exact correction I was looking for. Pain is usually an indication that the soft tissues in the areas have reached their limit of “stretch” and subjecting them to further injury may end up causing permanent damage.
The last thing that is of utmost importance is the education relating to pin care. After the device has been on for about two weeks, I start having my patients care for the device by swabbing the pins and the pinholes with Betadine twice a day everyday. I also tell them to continue to keep the area dry. I also educate them that if they note any drainage (other than light bleeding), odor, a sudden increase in pain, swelling, redness or trauma to the area, they should contact the office immediately.
If you are going to start putting this device and procedure into your arsenal, you can expect to have to deal with pin tract infections, even in the pediatric population. The last thing you want to have to do is admit a child for cellulitis with potential osteomyelitis because the patient did receive adequate education. This may happen due to non-adherence but you have to prepared and document accordingly.
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